It's a bittersweet entry this week, as this is my last blog as
an NUHS student. Sad right? I can't believe it's been a year and
half that I have been sharing my "wisdom" with everyone. It's been
an incredible three and half years. I know its cliché, but the time
really did fly by. It seems like yesterday I was sitting in
orientation with Dr. Stiefel, listening to how rigorous the next 3+
years of my life were going to be. He wasn't joking either. Those
first 2 years, I was a slave to my textbooks, notes, and
presentations. The load thinned out over this past year in clinic,
but the practice and studying was still and will always be a huge
part of my week to week.

Jeff, Guy, and I at a graduation dinner on Saturday.

I cannot thank our professors enough for the countless hours of
help and dedication they've put towards us:

I'd like to thank Dr. Jennifer "Vice-Grip"
Illes for being patient with me constantly nodding off
during her post-lunch E&M courses, and of course for teaching
me how to adjust!

The incredible Dr. Jaya Prakash helped me
understand pathology and microbiology in a way I never thought I
could.

Dr. Richard Leverone, Dr. Terry
Sandman, Dr. Heather "Awesome DACBR"
Miley, and Dr. Rudy Heiser made me
realize how much I love radiology, and who knows, maybe one day
I'll follow in their DACBR footsteps.

Then there is the always smooth, Dr. "Wiki-SRI-dia"
Sridharan Manavalan, who along with Dr. Leslie
Pearlstien, taught us the ins and outs of the human body
in anatomy class.

Who could forget the dynamic Lombard duo of Dr. Robert
Humphreys and Dr. Daniel Richardson? Dr.
Richardson always made class a blast, especially when he couldn't
find his glasses that were always resting on top of his head. I
can't thank Dr. Humphreys enough for allowing me to co-manage his
Florida neuro cases, and teaching me a lot of his tricks of the
trade along the way; and yes, I still owe you lunch, Doc.

How could I have gotten by without the incomparable Dr.
David "Coach" Seaman? I can break down the conversion
of just about anything you throw in your mouth to the enzymatic
level thanks my advisor and pal, Dr. Seaman.

I am more than confident in rehabbing just about any condition
that will walk into my office, thanks to Dr. Tim "You can
always be faster" Stark. Dr. Stark has always been there
with either quip or advice whenever I've approached him. Thank
you.

For the past year, Dr. Rudy "wild-assed-clinician award
recipient" Heiser, has molded and refined my clinical
skills. Dr. Heiser has let me learn through mistakes, treat in my
own way, and all the while made sure I was doing it correctly while
offering great advice along the way.

None of this would've been possible without the countless time
and effort put in by Dr. Joe Stiefel. Dr. Stiefel
not only taught, but administrated, and handled all the
behind-the-scenes activities that made the Florida Campus what it
is today.

Finally, I'd like to thank my mentor and friend, Dr.
Chad "The Intimidator" Maola. There is no way I would have
been the student, or the intern, or the doctor I am without all the
extra time Dr. Maola put in with me. I'll never forget the day
during my last final exam of third trimester, when he came in
halfway through the exam and told me to report to his office as
soon as I was done. The conversation Dr. Maola and I had that day
in his office is the reason I am as good and confident at what I
do. I know Dr. Maola has taken some flack over the years for the
extra time he has taken with me, but I want to let him know that it
never went unnoticed.

Enough with the goodbyes. My time at NUHS has been great. I
can't believe all that I've learned over the years, and all the
friends I've made along the way. Congratulations to the graduating
class of 2012!

Jeff, Guy, Dan, me, and Margaux

All of us down here have plans on practicing in Florida. Margaux
plans on pursuing veterinary chiropractic in the St. Petersburg
area, Dan Johns has his eye on a practice in Fort Lauderdale, Guy
Reshamwala is taking over one of his older brother's practice in
Hudson, Jeff Bourguignon will be independently contracting in
Tampa, and of course I will be opening my practice in Tampa as
well. My door will always be open, and I will continue to answer
any emails that come my way. Thank you to everyone who has read the
blogs, and Ms. Marie Olbrysh for allowing me to send in my thoughts
each week.

I'll leave everyone with an excerpt from one of my early blogs,
a fable I took from Aesop's fables: "Hercules and The Wagoner":

A carter was driving a wagon
along a country lane, when the wheels sank down deep into a rut.
The rustic driver, stupefied and aghast, stood looking at the
wagon, and did nothing but utter loud cries to Hercules to come and
help him. Hercules, it is said, appeared and thus addressed him:
'Put your shoulders to the wheels, my man. Goad on your bullocks,
and never more pray to me for help, until you have done your best
to help yourself, or depend upon it you will henceforth pray in
vain.'

Always take responsibility for what you are doing, and remember
that self-help is the best-help. Never stop learning, and never
stop practicing.

Hello everyone, and welcome to my penultimate NUHS blog. Yes, I
know it's going to be very sad when I am longer writing about my
entertaining weekends and insightful blunders with patients, but I
am sure you will be able to press on.

FSU vs. UF Game (Click photo to see full version)

Speaking of pressing on, I had to walk into the clinic this
morning with my head a little lower than I would've liked. I, as
some of you may know, am a huge Florida State Seminole fan. I love
my alma mater and have stuck with them through thick and thin, and
after this weekend, it will be no different. After a fantastic
Thanksgiving Thursday, my old roommate and best pal, Rich, made the
drive up to Tallahassee for one of the largest and long standing
in-state football rivalry games--FSU vs. UF. It felt great being
back in my old stomping grounds and hopes were high that we would
best the Gators. Unfortunately, our hopes were deflated, as we lost
a disappointing 37-26. To add insult to injury, my Tampa Bucs also
lost a close match up against the now 10 and 1 Atlanta Falcons. I
was not a happy camper last night, but some left over turkey, ham,
and casserole did help a little.

Being disappointed in sports is one thing, but what happens when
you become disappointed when treating a patient with no results? At
what point do you have to step back and realize that you may not be
able to help a patient? Then once you have made that realization,
whom do you send them to?

I have been writing mock narrative reports for the past week and
came across one of my old cases in which this happened. I took over
this particular patient from a graduating intern, who had been
treating her for lower back, right hip and right lower leg pain. We
had established that the patient had lumbar spine disc derangement,
decreased core stability from two cesarean sections, and peripheral
nerve entrapment of the peroneal nerve in the right lateral
compartment of the lower limb as well as a pretty substantial
gluten allergy. This patient was treated 2-3 times per week
depending on her schedule, and would find mild relief after
treatments, but after two months at this frequency she was still
not experiencing any lasting relief.

At this point I reevaluated the patient and began another course
of treatment. Prior, the patient was being treated with Cox Flexion
and Distraction. I then switched to McKenzie end-range loading
techniques (more extension-type therapy), which seemed to offer
longer lasting relief. Still a month went by with very little
change. Now, I started to pull my hair out. At that point I had to
have "the talk" with my patient about possibly finding another
treatment option. She was very apprehensive to any kind of
injection or surgery, which is understandable and very common. The
challenge then became finding another alternative to her care that
would benefit her and she would be comfortable with. Together we
decided that seeking out an established McKenzie certified
practitioner might help, as I am not totally comfortable with some
of the more advanced stages of McKenzie protocol. A month or so
went by before the patient called the clinic, but when she did it
was with good news and she was extremely happy that we made the
switch.

I never looked at the situation as a failure on my part, or that
I was losing a patient, because in the end something I did made her
better. This should always be the goal as a doctor. Money will come
and go, as will patients, and as stressful as it might be to keep
your lights on in practice, you have to be able to sleep at night
also. This patient ended up continuing to be treated by the other
practitioner, but she did refer her husband, who is still an active
patient.

I hope everyone has a quick and productive week. Everyone should
be studying for finals already. Studying early always helps with
the crazy amount of exams stacked in a two-week period. Make the
final push of the trimester a good one.

Hello everyone. I know I'm looking forward to only a
three-day week this week and the food-coma that will be induced
Thursday. I always look forward to Thanksgiving. I'm fortunate to
have a huge family, who are local for the most part, equipped with
two grandmothers who are incredible cooks, and one uncle who's a
chef. Not to toot our own horns or anything, but we do turkey-day
right.

Today I'd like to share with you, probably, one of my last case
presentations that walked into the clinic last Friday. This patient
presented with strange neck and upper shoulder pain that began 4-5
days prior. The patient could not pinpoint a certain action, or
mechanism of injury; he had not lifted anything heavy nor sustained
any trauma. As the patient was sitting and telling me his story I
could notice he was struggling with some nasal congestion. I then
began to ask the patient if he had been feeling sick as of late, to
which he answered that he had been fighting off some nasal
congestion and a sore throat for about a week. Ding, ding, ding! So
now we have a patient with some weird neck and upper shoulder pain:
that is worse with laying down for extended periods of time and
while on his drive to work; that feels better with massage during a
warm shower; who has been fighting off what sounds like an upper
respiratory infection. What's the next step? If you guessed a
physical exam to rule out any life-threatening conditions, you are
correct.

The patient was informed of the risks of a physical exam, he
consented, and off we went. Through the physical exam we ruled out
a disc issue and facet involvement. In fact, the only instigating
exam finding was pinpoint tenderness at a nodule at the right
suboccipital area (base of the skull), and the same in the area of
the left sternocliedomastoid muscle area (left side of the neck).
As soon as I palpated over these nodules, the patient would note
that was his pain generator. One should not jump to the conclusion
of muscle spasm just because palpating over a muscle is tender.
What caused that "knot" to form? This is where listening to the
patient is key, but not allowing the patient to give you a
diagnosis; that's why you are the doctor and they are the
patients.

Remember, that pesky sore throat? I did. I decided to take a
look down the patient's throat, and what did I find? His throat was
fiery red on the right side. Can you see where I'm heading from
here? Now here is where I only give myself an 80% (very generously,
if Dr. Maola has anything to say about it). I honed in on a throat
infection that was causing inflammation of lymph nodes beneath the
suboccipital and sternocliedomastoid muscles leading to neck and
upper shoulder pain. This made sense with the red throat, stuffy
nose, and alleviation of pain when the lymphatic chains were
manually drained by massage in a hot shower. Seems pretty sealed
up, right? Wrong.

Dr. Chad Maola, our dean of academic assessment and mentor of
mine, saw a very big flaw in my diagnosis. He asked me to take a
look inside the patient's ears. Sure as I'm writing this right now,
that poor patient's right ear was red as could be; an ear infection
was the root of all the pain! The ear infection was causing the
lymph nodes to swell, and the infection was draining down the
eustation tube (tube that connects the middle ear to the throat for
drainage) to the back of the patient's throat causing a sore
throat.

Image from Northwestern University

Now, I could have managed the patient for a throat infection and
manually drained the lymphatic chains and offered the patient some
relief, but what would have happened if I didn't notice the ear
infection. With an ear infection in adults, ear pain is an
end-stage symptom, right before tympanic membrane rupture. In real
life, if this patient came to me, paid me $80 or so for a
diagnosis, then had to turn around and head to an urgent care
clinic to spend another $80 for them to tell him that he in fact
had an ear infection rather than a primary throat infection, he
wouldn't be very happy.

I adjusted the patient's cervical spine which resulted in an
instant sensation of ear drainage and sent him on his way with some
instructions on dripping in some warm garlic olive oil into his
ear, continue to massage out his lymphatic chains in the shower,
and to seek a physician for antibiotic therapy to clear up the
infection. Sure enough, the patient felt ear pain that night, found
relief from the garlic olive oil, and after visiting his general
practitioner received an antibiotic prescription to resolve the
infection. The patient was happy, and I learned yet another
valuable lesson from Dr. Maola and my patient.

I hope today's entry helps someone down the line. Assess every
option and always allow the patient to tell you what their signs
and symptoms are, and then you diagnose them. I hope everyone has a
quick short week and a terrific Thanksgiving!

Hello everybody. Part IV boards are DONE!! This past weekend, my
fellow 9th and 10th trimester interns and I
had to hopefully make our last trip to Port Orange, Florida, for
board exams.

The first day was the Diagnostic Imaging exam. We were first
given very specific instructions on what to expect once the exam
began. Next, we were separated into groups and taken to our exam
rooms. In the room were 10 stations, each with a view box
containing 2 images. On my exam there was one MRI case and the rest
were X-ray images. You then had 4 minutes to review the cases and
answer two follow-up questions that either asked the next
appropriate step in managing the case, what the diagnosis was, or
what would we expect to see clinically with that patient.

The general consensus after Day 1 was that we were all very
prepared for that exam. To reward myself after Day 1, I took the
rest of the afternoon off, found a golf course, and played a quick
solo 18. This ended up being a great way to relax before Day
2.

Day 2 of Part IV boards began at registration bright and early
at 8 a.m. Again, we were given lengthy instructions and bussed to
the test site at Palmer College's main clinic. This part of the
exam was designed to assess us as if we were dealing with patients
in a real life setting. There were 3 stations where we had to take
a history on simulated patients, 5 orthopedic and neurological
testing stations, and 1 physical exam station--each station was
followed by two questions similar to the diagnostic imaging
questions. There were then 5 adjustment stations, in which you set
up a specific chiropractic adjustment on a patient and verbalized
how the adjustment would be performed to the examiner. All of the
stations lasted for 10 minutes before you were ushered to the next
station. It felt incredible walking out after that last station. I
felt confident and prepared for the exam, and hopefully I'll never
have to take another board exam again.

You know I had to mix in a little fun into the weekend after
tests like those. After Saturday's exam, I moseyed on down to
Tallahassee, Florida, for my good friend Nic's, wedding. Nic and I
were pals all through my college years at Florida State, and I
couldn't be happier for him. We danced and partied on Sunday well
into Monday morning.

It was a great weekend, and I'm looking forward to much less
stressful next 4 weeks before graduating Dec. 13.

It's an exciting day down here at the Florida campus; today the
NUHS Whole Health Center - Pinellas Park outpatient clinic is
open and ready for business. The other interns and I walked up this
morning to a fresh, state-of-the-art facility, which even has that
new clinic smell. It's an incredible facility, equipped with 10
treatment rooms, a physical therapy room, separate lab room, an
interactive classroom, and super-cool conference room. I am typing
this now from our very own intern lounge--pretty fancy.

Yes, we are very excited about all the brand-spanking-new
equipment, but we are also enthusiastic to have an outpatient
facility. Up until now, the Florida campus has had to get by with a
4-room clinic that only caters to the faculty, staff and dependents
of those affiliated with St. Pete College and the University
Partnership (which includes NUHS, Barry University, Florida State
University, University of Florida and others).

The new facility will now allow us to treat anyone and everyone.
The services we provide will still be free to the population we
would see at our student clinic, but will be at a very minimal cost
to anyone else who would like treatment. We are hoping that this
will open up a whole new population of patients, and bring some
more real-world cases through the door. The more practice we can
take on while in school will just help us feel that much more
confident once we graduate and are on our own.

Speaking of being on our own, I've started the process of
outfitting my clinic once I'm out of the NUHS nest. As many of my
colleagues and professors around here know, I've signed on to be an
associate with a great doctor, have signed a lease for my future
practice (opening in South Tampa, April 1, 2013...shameless plug),
and last week even bought almost all the physiotherapy equipment
I'll need. These things were a learning experience in and of
themselves. Finding the right location that you believe you can
succeed in is very important. I staked out the building I wanted
for nearly 2 years before it finally opened up about 2 months ago.
Then I was very fortunate to make a relationship with a local MRI
rep who clued me in on a practice that was downsizing and needed to
get rid of a lot of equipment for a very discounted price. From the
experiences I've had, I would recommend starting to make
relationships as soon as you can, and maintain them, even its just
a text or a phone call once a month to touch base. It goes a long
way.

I hope everyone has a productive week, and best of luck to
everyone taking Part 4 boards this coming weekend. Please everyone
wish us luck. I know we are all prepared, but a little luck never
hurts either. If anyone needs any help or advice about the new
clinic, or starting his or her own, please shoot me an email, its
fresh in my head, so hopefully I can help.